Chapter 10: Telepsychiatry

A psychiatrist is providing a weekly telepsychiatry clinic for a small rural community mental health center in the intermountain west. She evaluates a new patient, John a 74-year old recently widowed rancher whose children have brought him out of their concern of his increasing isolation. John reports that since his wife passed three months ago he has been having difficulty sleeping, leading to increasing fatigued during the day. He has lost his appetite and motivation to engage in ranch work or socialize with others. Although he denies current or history of suicidality, he feels that he has no reason to go on living and has access to firearms at home. The psychiatrist works with the clinic's onsite social worker to develop a treatment plan, which includes an antidepressant and sleep medication along with grief-focused supportive therapy. The psychiatrist educates John and his adult children about depression and loss and engages in a candid discussion about firearm safety in the context of a depressive episode and risks for suicide. The family agrees until the depression has resolved to hold John's firearms for him. Over the next 8 to 12 weeks through medication management and therapy John's depression begins to resolve, with the psychiatrist following John's progress in their follow-up video sessions and through contact with the clinic's social worker.

Technological advances have led to significant changes in psychiatric service delivery models. ¹ As broadband and wireless Internet access become widely available, and smart phones, tablets, and other small, portable devices allow convenient, mobile access to the Internet, virtual care options are expanding. These virtual options have emerged not only because of improved technological ability, but also because of an increasing recognition of the need to maximize the ability of a limited number of psychiatric providers to serve a larger patient population; a growing consumer demand for patient-centered, convenient care options; and payor demand for more cost-effective care. ² The American Medical Association (AMA) aptly notes that “[i]nnovation in technology, including information technology, is redefining how people perceive time and distance. It is reshaping how individuals interact with and relate to others, including when, where, and how patients and physicians engage with one another.” ³ Virtual modalities lend themselves particularly well to the field of psychiatry where providers need no peripheral devices or instruments for patient assessment or treatment. Through an increasingly diverse set of modalities and treatment models, telepsychiatry—defined broadly as leveraging audio and video technology to provide services from a distance ⁴ —is changing the nature of the traditional psychiatrist–patient relationship to a collaborative experience. This chapter is designed to describe the current treatment modalities and models that support the evolving practice, summarize the evidence for efficacy, and provide an overview of the pragmatic considerations related to telepsychiatry implementation across a variety of care settings.

Telepsychiatry uses two primary service delivery modalities, real time, also known as synchronous, and store-and-forward, also known as asynchronous. Synchronous modalities leverage audio and/or video technology for live, two-way interactive communication. This includes phone or video conferencing, both of which mimic in-person services and have the advantage of immediate response as part of real-time interaction. ⁵ In asynchronous applications, digital information, whether audio, video, or document format, is sent via email or other web applications to a specialist for later review. The sending and receiving parties do not need to be present at the same time. ^5,6

Telepsychiatry is implemented via direct and indirect consultation across a variety of models. Psychiatrists can directly prescribe medications, carry out psychotherapy, and maintain full responsibility for psychiatric treatment via televideo in any setting with appropriate privacy and connectivity. Psychiatrist expertise can be further maximized across a continuum of increasing indirect consultation with primary care providers (PCPs) and decreasing direct patient consultation. This continuum ranges from collaborative care models where virtual behavioral health teams apply population-based care within a primary care team, to consultation-liaison models where the psychiatrist consults directly with patients for diagnosis/evaluation and provides diagnostic and treatment recommendations to PCPs, to curbside consultations/case reviews with PCPs and no direct patient consultation. ⁷ Many integrated care models include both direct and indirect consultation. A well-known and well-researched collaborative care model is the IMPACT model (Improving Mood-Promoting Access to Collaborative Treatment) where psychiatrists participate in multidisciplinary primary care teams to provide feedback and treatment planning suggestions to PCPs. IMPACT's telepsychiatrists use electronic health record (EHR) messaging and provide phone/email curbside consultations for real-time advice on diagnoses, treatment plans, and medications. ⁸

Asynchronous applications still face reimbursement challenges, but have the potential to increase efficiencies across the continuum of models. Store-and-forward allows a more diverse and potentially less expensive pool of clinic staff to collect patient interview data using a semistructured, recorded format in settings like primary care medical homes, which are already convenient to patients. Recordings and patient medical records are sent to a psychiatrist for later review so psychiatrists can maximize smaller segments of unscheduled time. ^6,9–11 Emerging research shows this is more cost effective than either in-person or synchronous telepsychiatry service when economies of scale exceed 250 consultations per provider per year. ¹⁰

Historically, videoconferencing technology had a variety of logistical and financial obstacles. It demanded challenging audiovisual connections (including early microwave technology and closed-circuit television) and bulky fixed hardware, required dedicated technology support, and had high capital and labor demands. ^12,13 Because the hardware and transmission technology was so large and expensive, teleoptions were limited primarily to large academic medical institutions. ¹² Now, wireless Internet-based solutions make streaming audio and video for virtual psychiatric care feasible using secure, mobile, integrated, electronic platforms on laptops, cell phones, and tablets. The American Telemedicine Association (ATA) notes that Internet-based video conferencing needs a bandwidth of at least 500 Kbps in each of the downlink and uplink directions and a minimum of 640 × 480 resolution at 30 frames per second for all televideo applications, which applies equally to telepsychiatry. ¹⁴

Currently, most mobile devices include high-resolution video cameras and displays, Internet connectivity, audio inputs and outputs, and the processing power to support a variety of applications (apps) for patient data collection, patient monitoring, and treatment through synchronous and asynchronous modalities. ^1,15 Technological advances/apps already take advantage of accelerometers, technology embedded in smart phones to estimate WiFi activity and allow a global position system (GPS) to locate the device to track general user activity (eg, fitness “steps”). Research is underway to assess the utility of this existing technology to collect user activity data that may help assess for depression, ¹⁶ mania, ¹⁷ and psychotic disorders. ¹⁸ Other researchers are looking into the potential for avatar therapists, or virtual animations trained to respond therapeutically to patients’ movements and language. ¹⁹

Technologic advances in audio solutions, such as interactive voice response (IVR), have furthered the ability of both PCPs and psychiatric providers to support patient engagement in behavioral health treatment. Using IVR, primary care providers have been able to screen patients for alcohol abuse and engage them in brief alcohol intervention. Patients randomized to IVR-enhanced intervention had higher rates of substance use disclosure and higher rates of treatment engagement, and received more informed behavioral and medication recommendations compared to those receiving intervention with no follow-up-call enhancement. ²⁰

Telemental health has been characterized as having more randomized controlled trials than any other medical discipline area. ²¹ The telepsychiatry literature shows a growing consensus regarding the efficacy, feasibility, and acceptability of virtual psychiatric services. ^21,22 Telepsychiatry has demonstrated efficacy along the continuum of services—from psychoeducation, to assessment, diagnosis, and treatment. ²² It has been used to treat a wide variety of behavioral health diagnoses, including depression, anxiety, bipolar, posttraumatic stress disorder, eating disorders, and schizophrenia, and is associated with increased treatment engagement and adherence, improved symptoms, fewer hospital admissions, and shorter hospital stays. ²² In a comprehensive review of telemental health, Bashshur and colleagues ²¹ noted consistent evidence that virtual psychiatric and other mental health services are linked to improved quality of life and symptomology indicators across demographically and diagnostically diverse groups of patients. Virtual treatment modalities have had a significant impact upon psychiatric care access, particularly for historically underserved populations such as rural residents, college students, veterans, native populations, and incarcerated persons. ² Acceptance rates show that patients and providers comfortably use telehealth platforms ⁵ with some subgroups of patients (ie, patients who are younger, immobile, elderly, worried about stigma, or on the autism spectrum) reporting a preference for virtual over in-person care. ^15,23,24

As previously noted, telepsychiatry is showing particular success in improving care access through integrated care models. Virtual care platforms enable workforce multiplication, through which one psychiatric provider can provide consultation to primary care and other medical providers, thereby improving their ability to manage psychiatric symptoms and medication across their entire patient population. Team-based, primary-care depression care models with virtual psychiatry are associated with measures of patients’ treatment satisfaction and adherence, symptom reduction, and quality of life that exceed usual care treatment outcomes. ²¹ Future research will move beyond measures of feasibility and efficacy and inform effective means of telepsychiatry implementation into health care systems. ²⁵

With the ever-increasing evidence base for efficacy, feasibility, and acceptability, reimbursement and other regulatory issues may represent the final challenge to telepsychiatry expansion. ² Although Medicare, Medicaid, and increasing numbers of third-party payors reimburse for telepsychiatry treatment, constraints on reimbursable activities, originating (patient location) site, and the ability to reimburse at subsets of federally designated provider sites (ie, rural health centers) still challenge providers and systems in developing and sustaining telepsychiatry. As of late 2016, 46 states allow Medicaid reimbursement for telemental health services provided via live video (to approved originating sites) and 24 states have mandated that telehealth be covered by third-party payors—but uniform coverage for telepsychiatry and other virtual mental health modalities is lacking. ¹² Some home-based telepsychiatry is occurring, but is often only delivered through self-pay options and by private telepsychiatry companies. This form of payment and care is especially suited to those who want enhanced privacy and may not even want their insurance companies to know that they are seeking psychiatric treatment.

As previously noted, asynchronous telepsychiatry options may have a particularly high potential to increase care access and decrease costs. This is especially so in capitated systems of care. Asynchronous telepsychiatry is likely part of the future world of accountable care organizations and with the payment models being introduced in 2018–2019 in the United States through the Medicare Access & CHP Reauthorization Act of 2015 (MACRA) and the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs), all of which will substantially reform Medicare, and consequently all private insurance programs. It is highly likely that these reforms will lead to dramatically more telepsychiatry in general, both synchronous and asynchronous.

Originating Medicaid sites can bill for a facility fee (currently, a $25 reimbursement for providing the physical and administrative structures needed for the patient visit), which provides some telepsychiatry-related income. However, the inability to bill for services beyond direct patient treatment still minimizes the ability of providers and systems to realize the full efficacy and cost efficiency of telepsychiatry solutions. The majority of reimbursement challenges are not specific to telepsychiatry and represent general telehealth obstacles. Given the particular shortage of psychiatric providers, the huge burden of untreated mental illness, ²¹ and the significant opportunity to increase psychiatric care access through workforce multiplication using virtual means, these challenges are particularly critical.

Telepsychiatry has great potential to improve care quality and health outcomes. The change in the power structure of the doctor–patient relationship makes consumer engagement more likely, both through the more personal and flexible interactions with providers and through the opportunities for behavior modification using a number of psychotherapeutic approaches that have become solidly evidence based. ²¹ Telepsychiatry is also improving clinical efficiency, especially in integrated care systems, by easing the impact of provider shortages—in particular, psychiatrists—as well as improving care coordination, increasing staff efficiency, and speeding up access to appointments with experts. As noted later, the research evidence shows improvements in both patient symptoms and outcomes (ie, emergency department use), all of which can contribute to improved care, financial savings, and a clear return on investment. ⁷

Telepsychiatry is, by definition, dependent upon technology, making technology glitches a significant potential pitfall. The stability and strength of Internet connections vary from clinic to clinic, as do the quality of computers, webcams, speakers, and other hardware. Some sites may have IT support, some may not. Conducting a baseline technological assessment at the outset of a telepsychiatry program allows for early identification and resolution of technology issues. ²⁵ Technological requirements are determined primarily by the platform used and are often associated with minimum standards set forth by the service provider. ²⁶ Baseline technology assessments at newly implementing clinics should include a full complement of both technological and workflow questions (see Table 10-1).

Introducing a virtual medium into a physical clinic, such as a community mental health center or a primary care clinic, also includes pragmatic workflow challenges. Scheduling patients across both virtual and in-person visit types creates opportunity for potential pitfalls that can be avoided through strong communication and planning. Including front desk/receptionist team members as early telepsychiatry “champions” or early adopters can be particularly helpful. These staff members often hold key insights regarding workflow components that make the most sense within current clinic practices and that are likely to optimize the patient—and the provider—experience. Well-trained front desk staff improves the likelihood that technology will be set up accurately and consistently, telepsychiatry providers will be scheduled appropriately, and patients will be receptive to telemedicine modalities due to a positive and smooth experience. Further, ensuring that the staff responsible for scheduling patients have established communication channels with, and up-to-date availability information for the virtual psychiatrist, can avoid an underutilized psychiatrist. ²⁷

As telepsychiatry is implemented across increasing numbers of diverse settings, there are lessons to be learned about the best ways to improve and maintain the quality of telepsychiatry service delivery. Practitioners who have embarked on this virtual modality cite communication as a critical focus for improving the quality of telepsychiatry workflows. Unlike in traditional psychiatry settings, members of originating and distant telepsychiatry site teams do not see, or even communicate with, each other every day. Virtual teams can work as efficiently as traditional teams with a program design that fosters clear communication channels and ongoing quality improvement. ²⁵ Establishing systematic processes for regular ongoing communication can maintain a focus on quality. It is recommended that telepsychiatry implementation teams create a venue, such as monthly telehealth team meetings, to quickly identify and troubleshoot workflow issues to prevent escalation. ²⁵ Clearly articulating, reviewing, and refining clinic workflow to include scheduling, patient referral, and documentation improves the implementation experience. Implementation success is much more likely when all clinic staff members, from front desk administrative assistants to medical directors, understand their role in the process. ²⁵

Although a virtual medium does not change the practice or ethical responsibilities of psychiatry, it does expand the patient population and types of care settings in which a psychiatrist may practice. Further, the opportunities for team-based care may mean that a psychiatrist has varying levels of accountability for different patients on her or his caseload. Psychiatrists are responsible for maintaining an appropriate level of cultural competency across all patients served and for being accountable for participating appropriately within a variety of clinical workflow models. In addition, there are ethical considerations specific to telepsychiatry. Patient security and information privacy considerations are at the forefront of virtual care. According to the AMA, physicians, including psychiatrists, are responsible for confirming that their telemedicine service/platform comes with appropriate protocols to prevent unauthorized access and to protect the security and integrity of patient health information during transmission and at both patient and provider ends of the electronic encounter.

They note that ethically sound care via virtual mediums include:

1. Informing patients about the limitations of the provider/patient relationship and virtual services

2. Confirming each patient's identity and that telepsychiatry is an appropriate medium for the patient's individual situation and medical needs

3. Tailoring the informed consent process for patients (or their surrogates) to include information about the virtual medium, in addition to standard medical and treatment information

4. Demonstrating proficiency with relevant technologies and comfort with virtual interaction

5. Recognizing any limitations of the technologies used and taking appropriate steps to overcome those limitations (ie, having a phone call back-up plan for videoconferencing outages)

6. Advising patient and other provider users about how to arrange for needed follow-up care as indicated

7. Appropriately documenting the clinical evaluation and outcomes

8. Taking steps to support continuity of care by making records accessible to patients and encouraging sharing with patients’ primary care providers

Other ethical practices include disseminating information about both positive and negative treatment outcomes associated with the medium and advocating for policies that promote greater health care access such as through telepsychiatry.

Patient consent, in particular, is addressed in state legislation and in the ATA's Core Operational Guidelines. These state that “[o]rganizations shall have a mechanism in place for ensuring that patients and health professionals are aware of their rights and responsibilities with respect to accessing and providing health care via telehealth technologies (whether within a healthcare institution or other environment such as the home, school or work), including the process for communicating complaints.” ²⁶ Specific to telemental health, the ATA notes the best practices include reviewing confidentiality, emergency plans, process by which patient information will be documented and stored, potential for technical failure, and the procedure for coordination of care with other health professionals. Processes for patient safety and emergency management, such as in the case of suicidal ideation, must be established with the originating site staff in advance of any patient session. Any such protocols should be aligned with all pertinent professional guidelines and should also be aligned with the originating site emergency and safety management protocols. ²⁶ Finally, providers have a fiduciary obligation to disclose any financial or other interests associated with the telehealth/telemedicine application or service and to make a reasonable effort to manage or eliminate any potential conflicts of interest. ³

Two very influential clinical guidelines have been published by the ATA. The first, published in 2009, ²⁸ focused mainly on telepsychiatry performed in a hub-and-spoke format to and from clinics and hospitals. This guideline has been adopted widely around the world in many telepsychiatry programs and provides detail with respect to clinical, administrative, technical, and regulatory issues. In 2013 a follow-up guideline was published that focused on the provision of telepsychiatry into the home environment. These guidelines are likely to be updated in 2017 to take account of the increasing use of mobile environments and the use of telepsychiatry in team-based care, especially in integrated primary care systems, as neither of the current published guidelines has enough of a focus on these areas. The core guidelines are supported by generic operational guidelines, an evidence-based review, and a lexicon of relevant assessment and outcome measures of relevance. ATA guidelines are accessible online. They include the following: 1) Core Operational Guidelines for Telehealth Services Involving Provider-Patient Interactions; 2) A Lexicon Assessment and Outcome Measurements for Telemental Health; 3) Practice Guidelines for Video-Based Online Mental Health Services; 4) Practice Guidelines for Videoconferencing-Based Telemental Health; and 5) Evidence-Based Practice for Telemental Health.

In summary, technological advances have enabled a diverse set of virtual psychiatric and integrated care models. Videoconferencing technology is increasingly being used to not only increase access to care, but also increase care quality and efficiencies through models that leverage both direct and indirect care in a variety of care settings. With a strong evidence base to support assessment, diagnosis, and treatment across a wide variety of mental health problems and across a wide variety of models, remaining challenges include policy and reimbursement and implementation efficacy and quality improvement. The ATA has a variety of web-based guidelines and resources that provide pragmatic help with implementation, and the AMA's recently published ethical considerations for telehealth support diffusion in a manner that is consistent with patient-centered values.